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NFPA 101 Life Safety Code (2012 Edition)

19.2 Means of Egress Requirements

19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11.

7.1.6.2 Changes in Elevation. Abrupt changes in elevation of walking surfaces shall not exceed 1/4 inch. Changes in elevation exceeding 1/4 in., but not exceeding 1/2 in., shall be beveled with a slope of 1 in 2. Changes exceeding 1/2 in, shall be considered a change in level and shall be subject to the requirements of 7.1.7.

Based on observation and interview, the facility failed to ensure all walking surfaces located at the exit discharge areas of the facility were free of obstructions/impediments (tripping hazards/elevation changes). Not having all walking surfaces free of obstructions/impediments and available for full instant use could result in fall injuries or delay of evacuation in the event of an emergency or fire. This deficient practice presents a risk of injury to any patient, staff or occupant, who could potentially utilize the walkway from exit discharge locations. The findings are:

A. On 04/01/21 at 9:30 am, observation of the concrete walking surfaces located on the northeast side of the facility, near the exit from medical surgical, had depressions/concaved areas in the concrete greater than 1/4 inch. The affected area is approximately six (6) feet in length.

B. On 04/01/21 at 9:45 am, observation of the concrete walking surfaces located on the southwest side of the facility, near O.R. exit/entrance revealed the change is elevations on the walking surfaces were greater than 1/4 inch in height. The affected area is approximately four (4) feet in length.

C. On 04/01/21 at 9:50 am, during interview, the Maintenance Supervisor stated repairs to the concrete would be made as soon as possible.

Reference; NFPA 101, 2012 Edition

19.3.4 Detection, Alarm, and Communications Systems.
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

19.3.6 Corridors.
19.3.6.1 Corridor Separation. Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5 (see also 19.2.5.4), unless otherwise permitted
by one of the following:
(1) Smoke compartments protected throughout by an approved supervised automatic sprinkler system in accordance with 19.3.5.8 shall be permitted to have spaces that
are unlimited in size and open to the corridor, provided that all of the following criteria are met:
(a)*The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas.
(b) The corridors onto which the spaces open in the same smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the smoke compartment in which the space is located is protected throughout by quick-response sprinklers.
(c) The open space is protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the entire space is arranged and located to allow direct supervision by the facility staff from a nurses ' station or similar space.
(d) The space does not obstruct access to required exits.
(2) In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.8, waiting areas shall be permitted to be
open to the corridor, provided that all of the following criteria are met:
(a) The aggregate waiting area in each smoke compartment does not exceed 600 ft2 (55.7 m2).
(b) Each area is protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or each area is arranged and located to allow direct supervision by the facility staff from a nursing station or similar space.
(c) The area does not obstruct access to required exits.
(3)*This requirement shall not apply to spaces for nurses ' stations.

9.6 Fire Detection, Alarm, and Communications Systems.
9.6.1* General.
9.6.1.1 The provisions of Section 9.6 shall apply only where specifically required by another section of this Code.
9.6.1.2 Fire detection, alarm, and communications systems installed to make use of an alternative permitted by this Code shall be considered required systems and shall meet the provisions of this Code applicable to required systems.
9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and
NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.
9.6.1.4 All systems and components shall be approved for the purpose for which they are installed.
9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code.



Based on observation and interview, facility failed to ensure a smoke detection devices were installed in the enclosed courtyards. Not having detection devices installed in all waiting/meeting areas greater than 600 sq. ft., open to the corridor, could result in an undetected fire, which presents a risk of potential harm by fire to all patients, staff and occupants within the facility. The findings are:

A. On 04/01/21 at 10:35 am, during observation of the court yards (2 - located within the facility), which are both covered, enclosed and sprinklered. Both areas were found with no smoke detection device installed.

B. On 04/01/21 at 10:50 am during interview, the Administrator and Maintenance Supervisor indicated smoke detection devices would be installed in both court yards.

Reference; NFPA 101, 2012 Edition

19.3.5 Extinguishment Requirements.
19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise
permitted by 19.3.5.5.

9.7.1 Automatic Sprinklers.
9.7.1.1* Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following:
(1) NFPA 13, Standard for the Installation of Sprinkler Systems
(2) NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes
(3) NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in height.


Reference; NFPA 13, 2010 Edition
13.7 Fire Department Connections.
13.7.1 Fire department connections shall be inspected quarterly to verify the following:
(1) The fire department connections are visible and accessible.
(2) Couplings or swivels are not damaged and rotate
smoothly.
(3) Plugs or caps are in place and undamaged.
(4) Gaskets are in place and in good condition.
(5) Identification signs are in place.
(6) The check valve is not leaking.
(7) The automatic drain valve is in place and operating properly.
(8) The fire department connection clapper(s) is in place
and operating properly.


Based on observation and interview, facility failed to ensure all fire department connections(FDC), were identified by signage. Not having all FDC's identified by signage could result in the delay of the emergency responders supplying the sprinkler system with additional water in the event of an emergency. This deficient practice presents a potential risk of injury to all patients, staff and occupants within the facility. The findings are:

A. On 04/01/21 at 9:45 am, observation of FDC located at the southwest corner of facility was found with no identifying signage.

B. On 04/01/21 at 9:50 am, during interview, the Maintenance Supervisor stated the proper sign would be installed.



Reference: NFPA, 101 Life Safety Code, 2012 Edition

19.3.5 Extinguishment Requirements.

19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7

9.7 Automatic Sprinklers and Other Extinguishing Equipment.
9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this code shall be inspected, tested and maintained in accordance with NFPA 25, Standard for the Inspection, Testing and Maintenance of Water Based Fire Protection Systems.

Reference; NFPA 25 Standard for the Inspection, Testing, and Inspection of Water-Based Fire Protection Systems, (2011 Edition)

14.2 Internal Inspection of Piping.
14.2.1 Except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and by removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material.
14.2.1.1 Alternative nondestructive examination methods shall be permitted.
14.2.1.2 Tubercules or slime, if found, shall be tested for indications of microbiologically influenced corrosion (MIC).
14.2.1.3* If the presence of sufficient foreign organic or inorganic material is found to obstruct pipe or sprinklers, an obstruction investigation shall be conducted as described
in Section 14.3.


Based on record review and interview, the facility failed to ensure an internal pipe inspection was conducted for the fire sprinkler system every 5 years. Not having an internal pipe inspection conducted every 5 years could result in the failure of the sprinkler system due to damaged pipes, obstructions, or build up of organic or inorganic material, which could result in the failure of the sprinkler system. This deficient practice presents a risk of potential harm to all patients, staff and occupants within the facility. The findings are:

A. On 03/31/21, during record review of sprinkler system servicing documentation, no documentation was provided to indicate the facility had a 5 year internal pipe inspection within the last 5 years.

B. On 03/31/21 at 11:05 am, during interview, the Maintenance Supervisor stated he did not know if an internal pipe inspection had been conducted within the last 5 years.

C. No further documentation was presented for review.

Reference: NFPA 101 Life Safety Code, 2012 Edition

19.5 Building Services.
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.
19.5.1.2 Existing installations shall be permitted to be continued in service, provided that the systems do not present a serious hazard to life.
19.5.2 Heating, Ventilating, and Air-Conditioning.
19.5.2.1 Heating, ventilating, and air-conditioning shall comply with the provisions of Section 9.2 and shall be installed in accordance with the manufacturer's specifications, unless otherwise modified by 19.5.2.2.

9.2 Heating, Ventilating, and Air-Conditioning.
9.2.1 Air-Conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air-conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with
NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless such installations are approved existing installations, which shall be permitted to be continued in service.


5.4.8 Maintenance.
5.4.8.1 Fire dampers and ceiling dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protective's.

NFPA 80 Standard for Fire Doors and Other Opening Protective's, 2010 Edition

19.4* Periodic Inspection and Testing.
19.4.1.1 The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years.

Based on record review and interview, the facility failed to ensure fire/smoke dampers located within facility were maintained at least every six (6) years as required by NFPA 80 (Standard for Fire Doors and other Opening Protective's). Not maintaining the fire/smoke dampers per the NFPA frequency requirement could result in the distribution of smoke, hot gases and fire from area to area via the heating and ventilation air duct system in the event of fire, this deficient practice presents a potential risk of harm to all patients, staff and occupants within the facility. The findings are:

A. On 03/31/21, during record review of the Damper Inspections, no documentation was provided to ensure dampers were inspected every 6 years as required.

B. On 03/31/21 at 11:30 am, during interview, the Maintenance Supervisor stated he could not locate the servicing documentation and did not know if the service was conducted within the last 6 years.

NFPA (National Fire Protection Association) 101 Life Safety Code 2012 Edition

19.3.2.4 Medical Gas, Medical gas storage and administration areas shall be in accordance with Section 8.7 and the provisions of NFPA 99, (Health Care Facilities Code), applicable to administration, maintenance, and testing.

NFPA 99 (Health Care Facilities Code), 2012 Edition

5.1.14.4 Medical Gas and Vacuum Systems Maintenance and Record Keeping. See B.5.2
5.1.14.4.1 Permanent records of all tests required by 5.1.12.3.1 through 5.1.12.3.14 shall be maintained in the organization's files.
5.1.14.4.2 The supplier of the bulk cryogenic liquid system shall, upon request, provide documentation of vaporizer(s) sizing criteria to the facility.
5.1.14.4.3 An annual review of bulk system capacity shall be conducted to ensure the source system has sufficient capacity.
5.1.14.4.4 Central supply systems for nonflammable medical gases shall conform to the following:

(1) They shall be inspected annually.
(2) They shall be maintained by a qualified representative of the equipment owner.
(3) A record of the annual inspection shall be available for review by the authority having jurisdiction.


Based on record review and interview, facility failed to ensure deficiencies noted on medical gas/vacuum, annual report were corrected. Not maintaining medical gas systems as required could result in the failure of the system to supply medical gas to the patients, which presents a risk of potential harm. The findings are:

A. On 03/31/21, at 10:05 am, during record review medical gas/vacuum systems report dated 08/21/21, indicated deficiencies noted on the medical gas report, had not been addressed/corrected.

B. The following items identified on report medical gas/vacuum report, (dated 08/20/20).
1. Alarm panel in Pre-Op/Post-OP (Station 2), oxygen module not working.
2. Medical vacuum hour meter not working.
3. Medical air compressor hour meter not working.
4. Pre-Op/Post-Op, alarm O2 module not working.

C. On 03/31/21, at 10:08 am, during interview the Maintenance Supervisor, stated he did contact agencies for quotes on correction of deficiencies.